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North Andover Board of Assessors Public Access
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North Andover Board of Assessors
Property Record Card
Parcel ID :210/106.C-0051-0000.0 FY:2008 Community: North Andover
SKETCH
Click on Sketch to Enlarge
PHOTO
Location: 39 GRANVILLE LANE
Owner Name: FOTINO, JOHN L
ELLEN FOTINO
Owner Address: 39 GRANVILLE LANE
City: NORTH ANDOVER State: MA
Zip: 01845
Neighborhood: 6 - 6 Land Area:
1.59 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area:
2800 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 549,300 584,100
Building Value: 336,200 348,500
Land Value: 213,100 235,600
Market and Value: 213,100
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=1181553&town=NandoverPubAcc 8/15/2008
� Commonwealth of Massachusetts [RECEIVED-�City/Town of UN U 9System Pumping Record OFNUn , ,N'DOIJERFpm 4 LTH DEPART MEiVT
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
"Q
ISI
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1.
System Location:
(
l l ;
Address
Citylrow n
2. System Owner:
Name
Address (if different from location)
G -e. ,
State
V\'0
Zip Code
City/rown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date 2. Quantity Pumped: Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes I -No
5. Con 'tion of Syst �` 0
1-e�
6. System Pumped By:
Name
Company
7. Locatrer Conten disposed:
If yes, was it deaned? ❑ Yes ❑ No
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record . Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 �;� 1 '12014
TOWN OF NORMANDOVER
DEP has provided this form for use, -by local Boards of Health. Other forms mayber.�iseaTabalaNT
information must be substantially the same as that provided here. Before using this form, check with your
local. Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left ight fron�nildifig,
Left/ Right rear of house/ rig s' of Nous Left /
Right side of building, Le Left / Right rear of bul ding, Un
Add
��
City/Town State Zip Code
2. System Owner.
Name
Address (if different from location)
Citylrown
State � ,., Z � (}' —OSS 7Zp Code
Telephone Number 'w
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 03/Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? L1Y Yes ❑ No If yes, was it cleaned? 03/Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell. Bateson
Name i
Bateson Enterprises Inc -
Company.
7. Location where contents were disposed:
_Lowell Waste Water
F5821
Vehicle License Number
Date
t5fbrm4.doc- 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
W City/Town of
' System Pumping Record
Form 4
RECEIVED
12013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use, by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left Aziiiont of house Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address �
Cityrrown state Zip Code
2. System Owner.
Name
Address (if different from location)
Cityrrown t State C d� pe
relephone Number
B. Pumping Record
r j.-- a--�3 /��
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) U -Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ No.
5. Condition -off System 1
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S., _ Lowell Waste Water
—f
F5821
Vehicle License Number
'�Z� -��3
Date
d
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
w
PUBLIC HEALTH DEPARTMENT
Community Development Division
EWCOPY
(E127I�F'ICA7E Off' CO�I�1�1'GIATI�E
As of:
Jufy 161 2009
This is to cert that the indviduaCsu6surface disposal system received a
SAV FAC` ORT INST EMON of the.
impair/placement of Complete Septic System
By,.
L
Teter Breen
At:
39 Granvilre .Gane
Wap —106. C; Parcef— 51
North Andover, M,4 01845
The Issuance of this cert Rate shall not 6e construed as a guarantee that the system wiff
function satisfactorily.
us n 2: Sawyer
(P'u6fac Ifeafth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
f Na�rrff �
p t`�.ao .a• N�
SSACFiUSE
PUBLIC HEALTH DEPARTMENT
Community Development Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (,�repaired;
By:
(Print Name)
Located at: 6 PlktiV1
(Installation Address)
RECEIVED
JUL 0 6 2009
HEALTH
Was installed in conformance with the North Andover Board of Health approved plan, originally dated
_ _ 11tq� - and last revised on i V—'T -- with a design flow of
44--o— gallons per day. The materials used were in conformance with those specified on the
approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local
regulations, and the final grading agrees substantially with the approved plan. All work is accurately, represented on
the As -built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:
A
And — Print Name
Final Construction Inspection Date:
V21 LL- PU OM�6_4
And — Print Name
Enginer:
1
VLAG'IMIR L.
(Signature)
Engineer Representative (Signature)
Engineer Representative (Signature)
Date
k
And — Print Name
ate: 6122 k
And — Print Name
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnerthandover.com
'.w. �yORT1i
J-" O��giED ,
32 6 f 4676 O
° FECOPY
PUBLIC HEALTH DEPARTMENT
Community Development Division
C�R7r�ICA7� OE Co�tPLrANCE
As of:
Jufy 16, 2009
This is to cert that the individual subsurface disposa(system received a
- SAr1ISFAC ORTINS(EMONof the:
2jfpair/placement of Complete Septic System
CBy:
Peter Breen
At:.
39 Granvilre .Gane
Kap —106. C; Parcel— 51
North Andover, 9I1A 01845
,ffw Issuance of this certificate shaft not 6e construed as a guarantee that the system wilt
function satisfactorify.
us n I Sawyer
1t 6fac 3feafth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
f No�atff q
� 9
c k �
4
— 4 e
9SSRCHU`�Ej
PUBLIC HEALTH DEPARTMENT
Community Development Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (.�repaired;
By:
(Print Name)
Located at: 6 K+E 0 V 1 LA19
(Installation Address)
RECEIVED
JUL 0 6 2009
WN-OF-ISIORTH.AI�COVER
HEALTH DEPARTMENT
Was installed in conformance with the North Andover Board of Health approved plan, orig;nally dated
and last revised on i ��� —fes , with a design flow of
gallons per day. The materials used were in conformance with those specified on the
approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local
regulations, and the final grading agrees substantially with the approved plan. All work is accurately, represented on
the As -built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:
And — Print Name
Final Construction Inspection Date:
And — Print Name
Installer:
Enginer:
V J/
Engineer Representative (Signature)
Engineer Representative (Signature)
'J GGC�/y (Signature) Date. _t
ve
VLADIMIR L.
IEMCHENOK � And — Print Name
�`r, jIVILM� (Signature) " Date: 6112 C3 .
PICY
pnk
�;ONAL 144.!/iC i� l:� v✓v',�
And — Print Name
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
JAK
NORTH
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PUBLIC HEALTH DEPARTMENT
Community Development Division
FILE COPY
CERTI F'ICA7E OF'CO�44PLIANCrE
As of:
,7uCy 16, 2009
This is to cert that the ind viduaCsu6surface disposa[system received a
SAVS FAC' ORT INSTEMON of the:
ftairIfthcement of Complete Septic System
By:
Teter Breen
At:
39 Granville Gane
9Kap—106.C; Parcel— 51
North Andover, JKA 01845
The Issuance of this certificate shard' not 6e construed as a guarantee that the system will
function satisfactorily.
- us n I�Sauy�er�"
ft 6fic Wealth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
No�r►�
Of4��mo �e'�R.Q
F � 9
�SSRC:tO
PUBLIC HEALTH DEPARTMENT
Community Development Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (,�repaired;
By: 176 f El/ f%/►'G��_1.i
(Print Name)
Located at: ?21 6 iLiEQV 1 U,6 -
(Installation
, (Installation Address)
RECEIVED
JUL 0 6 2009
HEAL
Was installed in conformance with the North Andover Board of Health approved plan, originally dated
and last revised on ��� —f9 , with a design flow of
'D gallons per day. The materials used were in conformance with those specified on the
approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local
regulations, and the final grading agrees substantially with the approved plan. All work is accurately, represented on
the As -built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:
___Oil A- r2uirI7. P-rx7ur-_
And — Print Name
Final Construction Inspection Date: _19
And — Print Naine
Installer:
Enginer:
Engineer Representative (Signature)
Engineer Representative (Signature)
i�r 'J c6e'y (Signature) Date:\ 4
vLADIMIR L.
rc,
IEMCHENOK, And — Print Name
fkivi ry (Signature) ate: 6122O
LRtia���`Q
�NON;fA;L
And — Print Name
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
c
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NORTN
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OL
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�A _OR4TED rPa���
PUBLIC HEALTH DEPARTMENT
Community Development Division
f 'E127I�F'ICATCF OF COqq�GIANCE
As of.-
July
f:
July 16, 2009
This is to cert that the individual su6surface disposal system received a
SA EAC7ORT INSPEC770N of the.
ftairlRq&cement of CompCete Septic System
By:
Peter Breen
At:
39 Granville .Gane
Wap —106. C; Parcel — 51
North Andover, AKA 01845
The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
XA 2'. Sawyer
Tu6Cic Ifealth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
*
f
PUBLIC
PUBLIC HEALTH DEPARTMENT
Community Development Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (,�repaired;
By:_�� 1,tOL f/rGG�
(Print Name)
Located at: � [ 6 PAO V 1 LLC- L o
(Installation Address)
RECEIVED
JUL 0 6 Zoos
WN.OE, NORTH. AI.DCIVER
HEALTH DEPARTMENT
Was installed in conformance with the North Andover Board of Health approved plan, originally dated
_ and last revised on f x7-1 —0 0 with a design flow of
gallons per day. The materials used were in conformance with those specified on the
approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local
regulations, and the final grading agrees substantially with the approved plan. All work is accurately, represented on
the As -built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date: f
F
And — Print Name
Final Construction Inspection Date:
And — Print Name
Installer• k, Cr (6,CIV (Signature)
Enginer:
t
Engineer Representative (Signature)
Engineer Representative (Signature)
Date:\
And — Print Name
ate: 6129
F ,g, iJA /,. /i /111F�,,, �,,z1A
And — Print Name
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
lt-
AS-BUILT CHECKLIST
�- LOT NUMBER, STREET NAME
r� ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
letb
RVE l
TIES TO LOT LINES & DWELLING,S -
a. FROM SEPTIC TANK
b. FROM LEACH AREA
✓ LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
✓ LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
ORIGINAL STAMP & SIGNATURE
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW ,_
LOCATION & ELEVATIONS OF BENCHMARK USED
i 3+ vt' S L,.a fit,,
P vvv,.,
;a 5 S
r-) K, � tat—
L-OInZrt -
"5
FINAL GRADEINSPE TIO
Date: / 0
Address:
ea -` LO ED?
SEEDED?
❑ COVER PER PLAN?
Other:
Page 1 of 2
Attachments can contain viruses that may harm your computer. Attachments may not display correctly.
DelleChiaie Pamela
From: Isaac Rowe [irowe@millriverconsulting.com] Sent: Fri 10/3/2008 4:16 PM
To: 'Daniel Ottenheimer'; Grant, Michele; irowe@miliriverconsulting.com; 'Marianne Peters'; DelleChiaie, Pamela;
'Randy Burley'; Sawyer, Susan
Cc:
Subject: 39 Granville Lane
Attachments: D 39 Granville Lane Disapproval Letter 10-2-08.doc(222KB)
Susan,
Please find attached a disapproval plan review letter for the above referenced property. You may want to
consult with the Con Com agent about the possible wetlands/stream to the left of the existing dwelling. It is not
shown on the plan but I did witness a possible resource area the day of soil testing. The wetland resource area
is most likely 100' away from the proposed SAS but it should be shown on the plan.
Also, there are no test pits in the proposed SAS. This should be viewed as a variance from Title 5.
Please let me know if you have any questions.
Thank you,
Isaac
Isaac M. Rowe, R.S.
Project Manager
Mill River Consulting
2 Blackburn Center
http://exchange2003.town.north-andover.ma.uslexchange/pdellechiaielInboxl39%20Granv... 10/3/2008
TOWN OF NORTH ANDOVER aE %40R7y q
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT ° -
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845 �9IT'S sEs{h
Susan Y. Sawyer, RENS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
ONSITE WASTEWATER STEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: �� MLOT:
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
❑Topography not appreciably altered
Comments:
A., --SEPTIC TANK
Bottom of tank hole has 6" stone base
❑ W h 1 1 d
Ij
-)O A 00's thy/
eep o e p ugge
�G 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
o `7 ❑
2, 55
(Visual or Vacuum Test or Water held for 24hrs)
Inlet tee installed, centered under access port
Outlet tee (gas baffle or effluent filter) installed,
centered under access port
24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
Hydraulic cement around inlet & outlet
Wastewater System Documentation — Feb 2006
Page 1 of 6
J
s/�
TOWN OF NORTH ANDOVER ttORTM �r
Office of COMMUNITY DEVELOPMENT AND SERVICES ,rte°4`"
HEALTH .DEPARTMENT p
«:
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845 "sS^CHUSE`4h
Susan Y. Sawyer, RENS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
Comments:
PUMP CHAMBER
❑ Bottom of tank. hole has 6" stone base
❑ Weep hole plugged
❑ Combo Tank installed. Size:
❑ 1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ 24" inch cover to within 6" of final grade installed over
pump access port
❑ Water tightness of tank has been achieved
Visual testing
❑ Hydraulic cement around inlet & outlet
Comments:
ADVANCED TREATMENT TECHNOLOGY
❑ Type of treatment device:
Comments:
❑ Installed per manufacturers requirements
❑ All components working. in accordance with
manufacturer's requirements
Wastewater System Documentation — Feb 2006
Page 2 of 6
TOWN OF NORTH ANDOVER poRrk
O `4t4ao ,'°q1'O
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36 M...
NORTH ANDOVER, MASSACHUSETTS 01845 �'TsRCH„e4`h
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
D -BOX
Comments:
SOIL ABSORPTION SYSTEM
d
Comments:
Installed on stable stone base
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Bottom of SAS excavated down to Ljayer, as
provided on plan
Size of SAS excavated as per plan
Title 5 sand installed, if specified on plan
3/4-1'/2" double washed stone installed
1/8-1/2" (peastone) double washed stone installed
Laterals installed and ends connected to header
Laterals vented if impervious material above
Orifices @ 5 & 7 o'clock positions
Gravel -less disposal systems: type, number and
location as per plan
Elevations of laterals installed as on approved plan
40 Mil HDPE barrier installed
Retaining wall (boulder / concrete / timber/ block)
Final cover as per plan
Wastewater System Documentation — Feb 2006
Page 3 of 6
TOWN OF NORTH ANDOVER
µperp
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
a
1600 OSGOOD STREET; Building 2-36
"� 9. ,_ •'
NORTH ANDOVER, MASSACHUSETTS 01845
9SSRGNUSE�
Susan Y. Sawyer, REHS/RS
978.688.9540 — Phone
Public Health Director
978.688.8476 — FAX
PRESSURE DISTRIBUTION
-- inch manifold
laterals installed with end sweeps
size:
material:
Squirt test ft in height
Equal distribution to all laterals
orifice size inch as per plan
Comments:
CONTROL PANEL
❑ Alarm &Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel:
❑ Rated for exterior if placed outside
Comments:
Wastewater System Documentation — Feb 2006
Page 4 of 6
TOWN OF NORTH ANDOVER F %&ORT!{
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT 4K
T
1600 OSGOOD STREET; Building 2-36.
NORTH ANDOVER, MASSACHUSETTS 01845
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public .Health Director 978.688.8476 — FAX
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
❑ Wetlands bordering surface
water supply or trib. (in Watershed)
Tank
SAS Sewer
❑
Property line
10
10 --
❑
Cellar wall
10
20 --
❑
Inground pool
10
20 --
❑
Slab foundation
10
10 --
❑
Deck, on footings, etc
5
10 --
❑
Waterline
10
10 101
❑
Private drinking well
75
1002 50
❑
Irrigation well
75
100
❑
Surface Water
25
50
❑
Bordering Vegetated Wetland ;
Salt Marsh, Inland / Coastal Banka
75
100
❑ Wetlands bordering surface
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland
bylaws
Wastewater System Documentation — Feb 2006
Page 5 of 6
water supply or trib. (in Watershed)
150
150
❑
Trib. to surface water supply
325
325
❑
Public well
400
400
❑
Interim Wellhead Prot. Area
❑
Reservoirs
400
400,
❑
Drains (wat. supply/trib.)
50
100
❑
Drains (intercept g.w.)
25
50
❑
Drains (Other) Foundation
10 (5)
20 (10)
❑
Drywells
20
25
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland
bylaws
Wastewater System Documentation — Feb 2006
Page 5 of 6
TOWN OF NORTH ANDOVER FORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES c`'� .o ,a�ti°L
HEALTH DEPARTMENT r
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845"Ss';CH„SF<th
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
SYSTEM ELEVATIONS
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Wastewater System Documentation — Feb 2006
Page 6 of 6
4'178
Town of North Andover
`'• .: HEALTH DEPARTMENT
,SSACN�Stt
CHECK #: L ' - _ / Z,
— V
LOCATION:
H/O NAME:
CONTRACT(
Tyne of Permit or License: (Check box)
0 Animal
❑ Body Art Establishment
❑ Body Art Practitioner
❑ Dumpster
❑ Food Service - Type:
❑ Funeral Directors
❑ Massage Establishment
❑
Massage Practice
❑
Offal (Septic) Hauler
❑
Recreational Camp
❑
Sun tanning
❑
Swimming Pool
❑
Tobacco
❑
Trash/Solid Waste Hauler
❑
Well Construction
SEPTIC Systems:
❑ Septic - Soil Testing
❑ Sep i - Design Approval
�/'S/eptic Disposal Works Construction (DWC)
❑ Septic Disposal Works Installers (DWI)
❑ Title 5 Inspector
❑ Title 5 Report
$ 5"D-0'
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
$� Commonwealth of Massachusetts Map -Block -Lot
106.C- 0051 -
a4 Board of Health -----------------------
a Permit No
BHP -2009-0584
North Andover -----------------------
*
P.I.
, a FEE
'��'b-.t�a ,.•`SAF
Sg4cwu F.I. $250.00
Disposal Works Construction Permit
Permission is hereby granted Peter Breen
to (Repair) an Individual Sewage Disposal System.
at No 39 GRANVILLE LANE
as shown on the application for Disposal Works Construction Permit No. BHP -2009-058 Dated June 15, 2009
-------------
cod ------
Issued On: Jun -15-2009 Board of Health
o® "Lva`''Commonwealth of Massachusetts Map -Block -Lot
r .,4 a 106.C- 0051 -
. d.
-----------------------
Board of Health
North Andover
�s,CMU ¢� Certificate of Compliance
THIS IS TO CERTIFY, ThattheAe Disposal System (Repair)
by -_-Peter Breen
-----------------------------------------------------
-
at No 39 GRANVILLE L
has been installed ' accor ce with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Dispo orks Construction Permit No. BHP -2009-058 Dated June --15,20-09
------ ----
Printed On: Jun -15-2009 Board of Health
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
-Q
IL If
rewn
Application for Septic Disposal System 6/1 /5-le9
9
Construction Permit -TOWN OF TODAY'S DAT
�qORTH ANDOVER MA 01845 -0:00 - ull Repair
. 0 - Component
Application is hereby made for a permit to:
❑ onstruct a new on-site sewage disposal system*
Zpair or replace an existing on-site sewage disposal system*
❑ Repair or replace an existing system component - What?
A. Facility Information
WiLw
Address or Lot #
Itl", �TlTr1�ac. City/Town
d2 e -
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump [DlGravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
EInfiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information
(✓ 0
Name
Address (if different from above)
City/Town� State Zip Code
Telephone Number
3. Installer Information
Z-�i�-' Q �PiC--�- Yt°i%' i�%/\ �i�C L GL✓�T�'t C=t= �
Name /�,� % Name of Company
�_
77o "'�CI�D Ot l�`�y2Gr ✓
Address,• / /, [�—
City/Town State Zip Code
Telephone Number (Cell Phone # if possible please)
4. Designer Information
j�Ul—l—e_S-/1-e—
Name Name of Company
G6
Address
City/Town State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
Application for Septic Disposal System
0,6
-Construction Permit -TOWN OF
r ORTH ANDOVER, MA 01845
9 ScNueEt
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: aesidential Dwelling or ❑Commercial
B. Agreement
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
Name Date
lica iorrAppro lBoar of Health Represent live)
me Da
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached. Yes No
2. Project Manager Obligation Form Attached. Yes No
3. Pump System? If so, Attach copv ofElectrical Permit Yes No
4. Foundation As -Built. (new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit • Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
V.
As the North Andover licensed installer for the construction for the septic system for the property at:
3 1 cnl�_,A V i (I <_ (,q- /1, e -
(Address of septic system) For plans by
_ (Engineer)
Relative to the application of ��% S % '� �✓ �t�
(Installer's name) And dated /`�&io;` j�
rtgtna ate
Dated OC -7—
G
C� o y s ate With revisions dated G 7
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the appror ved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection, without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
MY company
a. Bottom of Bed – Generally, this is the first (1 s inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection – Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdept&townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade – Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: /,, t )1 gqo� (Today's Date)
Pc5-k<_e-' k (&—_,,_
7a—me – Print Tam – gne
r
Attachments can contain viruses that may harm your computer. Attachments may not display correctly.
DelleChiaie Pamela
From: DelleChiaie, Pamela Sent: Thu 10/23/2008 3:25 PM
To: jfotino@progress.com
Cc: brdufresne@comcast.net
Subject: 39 Granville Lane - Plan Approval - with LUA and Conditions - Forms 9A and 9B attached
Attachments: 11 SKMBT 60008102314500.pdf(304KB)
Mr. Fotino,
Here is your plan approval letter with conditions. The original will be sent via regular mail.
Pamela DelleChiaie
From: noreply@yourcopier.com [mailto:norepiy@yourcopier.com]
Sent: Thu 10/23/2008 3:50 PM
To: DelleChiaie, Pamela
Subject: Message from KMBT_600
Page 1 of 1
http://exchange2003.town.north-andover.ma.uslexchangelpdellechiaie/Sent%20Items/39... 10/23/2008
y w NORTIi aa
0, �t LE p 0 "l
3►r ° OL
O
O iwK� q.
�4 COCMIL MLWKM `y
S-CHus���y
PUBLIC HEALTH DEPARTMENT
Community Development Division
October 23, 2008
Jack Fotino
39 Granville Lane
North Andover, MA 01845
RE: Subsurface Sewage Disposal System Plan for 39 Granville Lane, North Andover, MA
Map 106C Lot 51
Dear Mr. Fotino,
The North Andover Board of Health has completed the review of the revised septic system
design plans for the above referenced property. These plans dated August 14, 2008, final revision
date of October 9, 2008, received on October 15th, have been approved for a four (4) bedroom,
maximum nine -room home.
In accordance with local subsurface disposal regulations "Acceptable plans and any variances
shall expire two years from the date approved unless construction on the lot has begun". During
this time, a licensed septic system installer must obtain a permit and complete this work, and a
Certificate of Compliance must be endorsed by the installer, designer and the Town of North
Andover.
This approval includes a Board of Health requirement in regards to the number of deep holes
located within the subsurface disposal area. Title 5, 310 CMR 15.102 requires that test pits be
conducted within the active area.
Due to the existing conditions of the property, the engineer chose to place the system upgradiant
of the test pits rather than over them. To allow the system to be installed as drawn, the following
is being required:
1) The request for a Local Upgrade Approval is not granted to allow zero test pits; rather
an L UA will be approved for a single test pit.
2) At the time of installation of the septic tank and excavation of the field, a deep hole will
be required in the area of the system. This deep hole shall be witnessed by a soil
evaluator and the Health Department staff.
This approval is also subject to the following conditions:
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
1. If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation, the originally issued Disposal System Construction
Permit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit (3 10 CMR 15.020(1)).
2. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and
municipal requirements are met. These may include review by the Conservation
Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
shall not construe and/or imply compliance with any of the aforementioned
requirements.
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health Department may be reached at 978-688-9540 with any questions you
may have.
Sincere
usan Y. Sawyer, RE /RS
Public Health Director
Encl: list of licensed septic system installers
Cc: Merrimack Engineering Services
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Commonwealth of Massachusetts
City/Town of
a y Local Upgrade Approval
Form 913
M
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well (explain):
min./inch
ft.
❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater
® Use of only one deep hole in proposed disposal area
❑ Use of a sieve analysis as a substitute for a perc test
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
N. Andover Board of Health
Approving Authority '
Susan Sawyer, Health Dir.
Print or Type Name and Title /)19 nature
10/23/08
Date
39 Granville Ln 9b 10.23.08 • rev. 7/06 Local Upgrade Approval* Page 2 of 2
Important:
When filling out
forms on the
computer, use
only the tab key
io move your
cursor - do not
use the return
key.
re4
t
Commonwealth of Massachusetts
Cityrrown of North andover
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR
15.404(1), is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full
compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410
through 15.415.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved
capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000.
A. Facility Information
1. Facility Name and Address:
Jack & Ellen Fotino Residence
Name
39 Granville Lane
Street Address
North Andover Ma
city/Town State
2. Owner Name and Address (if different from above):
Jack & Ellen Fotino
Name
North Andover
City/Town
01845
Zip Code
3. Type of Facility (check all that apply):
® Residential ❑ Institutional
4. Describe Facility:
4 BDRM. House
5. Type of Existing System:
39 Granville Lane
Street Address
Ma
State
(617) 513-1308
Telephone Number
❑ Commercial
❑ School
01845
Zip Code
❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other (describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
unknown
t5form9a.doc • rev. 7106 Application for Local Upgrade Approval, Page 1 of 4
P
Commonwealth of Massachusetts
CityfTown of North andover
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
C. Explanation (continued)
3. A shared system is not feasible:
NA
4. Connection to a public sewer is not feasible:
None available
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
❑ Application for Disposal System Construction Permit
® Complete plans and specifications
® Site evaluation forms
❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other (List):
D. Certification
"I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for s)*miVjng false information, including, but not limited to, penalties or fine and/or
imprisonmentfor dellb ate iolations."
,Jack Fotino L
Print Name
Bill Dufresne/Merrimack Engineering
Name of Preparer
66 Park Street
Preparer's address
Ma / 01810
State/ZIP Code
8-26-08
Date
8-26-08
Date
Andover
City/Town
(978) 475-3555
Telephone
t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval* Page 4 of 4
t4
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Wednesday, June 03, 2009 1:09 PM
To:'jim.kellettexcavating@comcas.net'
Subject: Granville Lane - Plan approved Oct. 23, 2008.
Attachments: S BT-60009060312510.pcl
Hi Jim,
Plan approved in Oct. of 2008. Please r d attache
information, let me know when you will b down to
you can submit the application via fax ahea of tim
come, you can just give me the check and the 'll gi
you definitely have the job first before I give to a
application off of our website. Go to Health Dep t
application, and obligation form, etc. Thanks.
P
d I tter and restrictions - items 1 & 2. Once you review the
ecluest an application - when you come in to sign 45 Forest? If so,
, so I can enter the information into the database, and when you
I
Pamela DelleChiaie /
Health Department Assistant
TOWN OF NORTH ANDOVER
Health Department
1600 Osgood Street
Building 20; Suite 2-36
North Andover, MA 01845
978.688.9540 - Phone
978.688.8476 - Fax
pdellechiaie@townofnorthandover.com - E-mail
http://www.townofnorthandover.com://www.townofnorthandover.com - Website
Notes:
you the plan that day if Susan approves. Let me know (ASAP) if
n for sign -off. See below number for fax. Also, you can print the
ment, Permits & Applications, and scroll down for septic - DWC
If copied to BOH Members - Reference Copy Only - no response requested at this time
From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com]
Sent: Wednesday, June 03, 2009 1:52 PM
To: DelleChiaie, Pamela
Subject: Message from KMBT 600
1
Page 1 of 1
Attachments can contain viruses that may harm your computer. Attachments may not display correctly.
DelleChiaie Pamela
From: DelleChiaie, Pamela Sent: Thu 10/23/2008 3:25 PM
To: Votino@progress.com
Cc: brdufresne@comcast.net
Subject: 39 Granville Lane - Plan Approval - with LUA and Conditions - Forms 9A and 96 attached
Attachments: 11 SKMBT 60008102314500.pC304KB)
Mr. Fotino,
Here is your pian approval fetter with conditions. The original will be sent via regular mail.
Pamela DelleChiaie
From: noreply@yourcopier.com [maiito:noreply@yourcopier.com]
Sent: Thu 10/23/2008 3:50 PM
To: DelleChiaie, Pamela
Subject: Message from KMIT 600
http://exchange2003.town.north-andover.ma.uslexchange/pdellechiaielSent%2Olterns/39... 10/23/2008
c NORTFf
61 O
O 1
� eb
�_ COCMI[M�kkCk 7'
PUBLIC HEALTH DEPARTMENT
Community Development Division
October 23, 2008
Jack Fotino
39 Granville Lane
North Andover, MA 01845
RE:. Subsurface Sewage Disposal System Plan for 39 Granville Lane, North Andover, MA
Map 106C Lot 51
Dear Mr. Fotino,
The North Andover Board of Health has completed the review of the revised septic system
design plans for the above referenced property. These plans dated August 14, 2008, final revision
date of October 9, 2008, received on October 15th, have been approved for a four (4) bedroom,
maximum nine -room home.
In accordance with local subsurface disposal regulations "Acceptable plans and any variances
shall expire two years from the date approved unless construction on the lot has begun". During
this time, a licensed septic system installer must obtain a permit and complete this work, and a
Certificate of Compliance must be endorsed by the installer, designer and the Town of North
Andover.
This approval includes a Board of Health requirement in regards to the number of deep holes
located within the subsurface disposal area. Title 5, 310 CMR 15.102 requires that test pits be
conducted within the active area.
Due to the existing conditions of the property, the engineer chose to place the system upgradiant
of the test pits rather than over them. To allow the system to be installed as drawn, the following
is being required:
1) The request for a Local Upgrade Approval is not granted to allow zero test pits; rather
an L UA will be approved for a single test pit.
2) At the time of installation of the septic tank and excavation of the field, a deep hole will
be required in the area of the system. This deep hole shall be witnessed by a soil
evaluator and the Health Department staff.
This approval is also subject to the following conditions:
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
1. If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation, the originally issued Disposal System Construction
Permit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit (3 10 CMR 15.020(1)).
2. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and
municipal requirements are met. These may include review by the Conservation
Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
shall not construe and/or imply compliance with any of the aforementioned
requirements.
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health Department may be reached at 978-688-9540 with any questions you
may have.
Sincere
usan Y. Sawyer, RE /RS
Public Health Director
Encl: list of licensed septic system installers
Cc: Merrimack Engineering Services
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Commonwealth of Massachusetts
— Cityrl-own of North andover
Form 9A - Application for Local Upgrade Approval
,w DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
.septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR
15.404(1), is not feasible.
Important:
When filling out
forms on the
computer, use
only the tab key
io move your
cursor - do not
use the return
key.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full
compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410
through 15.415.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved
capacity of an on-site system constructed in. accordance with either the 1978 Code or 310 CMR 15.000.
A. Facility Information
1. Facility Name and Address:
Jack & Ellen Fotino Residence
Name
39 Granville Lane
Street Address
North Andover
Cityrrown
2. Owner Name and Address (if different from above):
Jack & Ellen Fotino
Name
North Andover
City/Town
01845
Zip Code
3. Type of Facility (check all that apply):
® Residential ❑ Institutional
4. Describe Facility:
4 BDRM. House
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
Ma
01845
State Zip Code
39 Granville Lane
Street Address
Ma
State
(617) 513-1308
Telephone Number
❑ Commercial ❑ School
® Conventional ❑ Other (describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
unknown
t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval* Page 1 of 4
r. „
Commonwealth of Massachusetts
City/Town of North andover
o Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility:
B. Proposed Upgrade of System
unknown
gpd
440
gpd
440
gpd
1. Proposed upgrade is (check one):
® Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301:
date of inspection
2. Describe the proposed upgrade to the system:
New 1500 Gal. Septic Tank, gravity flow to a 830 S.F. leach field with 44 Infiltrator Chaniibers
3. Local Upgrade Approval is requested for (check all that apply):
❑ Reduction in setback(s) — describe reductions:
❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. % reduction
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction ft
Percolation rate
min./inch
Depth to groundwater ft
t5fonn9a.doc • rev. 7/06 Application for Local Upgrade Approval* Page 2 of 4
` Commonwealth of Massachusetts
Cityrrown of North andover
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
B. Proposed Upgrade of System (continued)
❑ Relocation of water supply well (explain):
❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater
Use of only one deep hole in proposed disposal area
❑ Use of a sieve analysis as a substitute for a perc test
—®--19thef requirements of 310 CMR 15.000 that cannot be met — describe and specify sections of the
Code:
existingNo !��-'Lt'i-Uleswi'tl'iliibiefjic)pose m but within close
existing smai and un ergroun _
proximity due
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Evaluators Name (type or print)
C. Explanation
Signature
Date of evaluation
Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
NA
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
NA
t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval* Page 3 of 4
4.
"Commonwealth of Massachusetts
City -town of North andover
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
C. Explanation (continued)
3. A shared system is not feasible:
NA
4. Connection to a public sewer is not feasible:
None available
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
❑ Application for Disposal System Construction Permit
® Complete plans and specifications
® Site evaluation forms
❑ .A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other (List):
D. Certification
"I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for s-ubml false information, including, but not limited to, penalties or fine and/or
,Jack Fotino L
Print Name
Bill Dufresne/Merrimack Engineering
Name of Preparer
66 Park Street
Preparer's address
Ma / 01810
State/ZIP Code
8-26-08
Date
8-26-08
Date
Andover
C4/Town
(978) 475-3555
Telephone
t5form9a.doc - rev. 7/06 Application for Local Upgrade Approval, Page 4 of 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 913
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
1. Facility Name and Address
Jack and Ellen Fotino
Name
39 Granville Lane
Street Address
North Andover
City/Town
2. Owner Name and Address (if different from above):
Name
City/Town
Zip Code
3. Type of Facility (check all that apply):
® Residential ❑ Institutional
4 Des' n flow er 310 CMR 15 203'
Jill
State
Street Address
State
Telephone Number
❑ Commercial
440
Ig p Vladimar Nemchenok
gpd
5. System Designer: Name
66 park Street Andover
Address City/Town
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s) — specify:
❑ Reduction in SAS area of up to 25%:
01845
Zip Code
❑ School
® PE
MA, 01810
State, ZIP
SAS size, sq. ft. % reduction
❑ RS
39 Granville Ln 9b 10.23.08 • rev. 7/06 Local Upgrade Approval, Page 1 of 2
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate min./inch
Depth to groundwater ft
❑ Relocation of water supply well (explain):
❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater
® Use of only one deep hole in proposed disposal -area
❑ Use of a sieve analysis as a substitute for a perc test
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
N. Andover Board of Health f
Approving Authority a
Susan Sawyer, Health Dir. . ' 10/23/08
Print or Type Name and Title signature Date
39 Granville Ln 9b 10.23.08 • rev. 7/06 Local Upgrade Approval* Page 2 of 2
1A
-------------- Original message ----------------------
From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
> Okay. We don't have any other recent submissions from you ...... are
> there any others we should be looking for??
> -----Original Message-----
• From: brdufresne@comcast.net [mailto:brdufresne@comcast.net]
> Sent: Tuesday, September 09, 2008 3:18 PM
> To: DelleChiaie, Pamela
> Subject: RE: 39 Granville Road - New Plan Review
> Thought you had that one for almost 2 weeks and the last review took
> only 10 days or so, sorry, I must have mistaken it for another
> submission.
> I'll wait to hear from you.
> Thanks,
> Bill
>-------------- Original message ----------------------
> From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
> > Bill,
> > We just received your application in the mail yesterday. It will be
> > going out for review today. I'm not sure why you thought it was
> already
> > in for review.
> > Pam
> > -----Original Message-----
* > From: brdufresne@comcast.net [mailto:brdufresne@comcast.net]
> > Sent: Tuesday, September 09, 2008 10:56 AM
> > To: DelleChiaie, Pamela
> > Subject: 39 Granville Road
> > Pam,
> > Checking on the status of the review for the above site. Please let
> me
> > know when and if there is any info.
> > My client, the owner, is inquiring and anxious.
> > Thank You,
> > Bill Dufresne
ft
North Andover Health Department
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 01845
978.688.9540 - Phone
978.688.8476 — Fax
healthdept�townofnorthandover.comcom - E-mail
www.townofnorthandover.com - Website
Letter of Transmittal
Page % of "-�
TO: WILLIAM (BILL) DUFRESNE, PROJECT MANAGER
O
it
`Tf(
Y Off_ CONI( lwK•
7' Y/
TO: WILLIAM (BILL) DUFRESNE, PROJECT MANAGER
DATE: / 7 /
/V &_ o
'e
COMPANY: MERRIMACK ENGINEERING SERVICES
FROM: Pamela DelleChiaie, Health Department Assistant
Fax #
Re:
Phone: 978.475.3555
Fax: 978.475.1448��
-12
We are sending you: 0,, �anftview Letter 17APPROVED
O System Construction Follow -Up
These are transmitted as checked below:
❑As Required 0 A Requested ❑For your File
O Other
O'
APPROVED
REMARKS:
COPY TO: Homeowner
Fax #
Or
Mailed
COPY TO:
Fax #
Or
Mailed
Fax #
COPY TO:
Or
Mailed
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��SS�ICHUS <�
Health Department
October 2, 2008
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover, MA 01810
Re: Subsurface Sewage Disposal System Plan for 39 Granville Lane, Map 106C, Lot 51
Dear Mr. Nemchenok:
The proposed wastewater system design plan for the above site dated August 14, 2008 and
received on September 8, 2008 has been reviewed. Unfortunately, the plan cannot be approved
until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or
North Andover regulation that is not met by this design follows each item.
s
1. There are no test pits in the proposed soil absorption system area. A Local Upgrade
Approval for only having one test pit in the soil absorption system area cannot be
requested. A variance from Title 5, 310 CMR 15.102 must be requested.
2. Please provide a scaled profile of the system (NA 8.02 c).
t,A. Please specify all system components shall be marked magnetic marking tape including
the septic tank (3 10 CMR 15.221(12)).
✓"4. Please note the outlet tee in the septic tank should extend 14" into the liquid and not 16"
(3 10 CMR 15.227(6)).
V-'5'.. Please show all the legal boundaries of the property (3 10 CMR 15.220(4)(a)).
f6. Please provide a north arrow on the site (3 10 CMR 15.220(4)(g)).
f 7. The design plan indicates the use of an effluent filter inside the septic tank. Please
indicate to the brand and model to be used. Also note the required annual maintenance
necessary (3 10 CMR 15.227(7)).
v""8 /Please show all watercoarses or wetlands within 150' of the system (NA 8.02(r)).
i Please provide a note that all the outlets of the d -box shall be at the same elevation (3 10
CMR 15.232(3)(b)).
10. Please provide soil evaluation forms 11 and 12 in accordance with 310 CMR 15.018(2).
'j
1600 Osgood Street HEALTH [SEPARTMENT Page 1 of 1
Building 20; Suite 2-36 E -Mail: healthdept@townofnorthandover.com
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
jS Sincere
in e
c
S san Y. Sawyer, REHS/aRz
Public Health Director
cc: Jack Fotino
File
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS - LAND SURVEYORS - PLANNERS
66 PARK STREEr - ANDOVER, MA 01810 - (978) 475-3555, 373-5721 * FAX (978) 475-1448 - E-MAIL lnfo@menimackengineedng.com
October 10, 2008
Susan Sawyer
Public Health Director
1600 Osgood Street
Building 20, Suite 2-36
North Andover, Ma. 0 1845
RE: 39 Granville Lane
Dear Ms. Sawyer:
RECM�VLD
OCT 15 2008
TOWN OF NORTH ANDOVF-R
HEALTH DEPART t,4E-NT
We received your review letter dated 10-2-08 for the above referenced site.
With regard to item #I of your letter, the new soil absorption system is placed directly
over the existing one, as such, test pits could not be performed within the.existing soil
absorption system and were excavated as close as possible to the area without being
influenced by sewage breakout. Both test pits indicate suitable soils and an excavation
inspection will be performed to further verify the suitability of soils beneath the proposed
soil absorption system. I don't believe it is the literal intent of Title 5 nor in the spirit of
Title 5 to require a costly and time consuming variance in this situation. This situation
arises regularly as systems are very often replaced in the same location and never in 13
years have we had this required in this or any other community.
)With regard to item #3, magnetic marking tape is not required if the system component
Zcan be magnetically located. In thiss case, the tank has ca=v Umn c,-j-vc—r-, ch cari hc
magnetically located and therefore tape i1a n I reqwred.
Whh regard io ft -em 97� the convactor and owner have the option of different brands of
M1,CT:-,'- 4JI-P.Ma.11-Ig on- costavaij and what procduct-thcir Tappliers carry. As a
-pe, On"' ffi-aLt ift confonn t Titl 5 o'
o pi 4c) e in terms
Y
.--,mremeA-. A n(-iie -h-aS beleR a4doed io specify !he requiremefit. for annual waintewance
ny - the tee filter -
T
W -114h reeard to item:98. a culvert and watercourse exist approximately 75 ft. to the vif-r-si
"oithc site, xA�cjll of T -413c pllysicai fimits 01-114c pian- T he 100 It. buiffer zone to tws
LU me
alu 101111
Lassity. wi-Ln rcgara to itcm U, wc navc occa P170 lamu a 1110GII cu SOLF11 CV -1 allk-in --
my other commul-twes., in- .1a' -L
10- r.=ny years winch has been acceptable to you and to mi -m
,- - 4:
it was developed by a neighboring Board of Health. Title 5 allows forms other than the
State form to be used. Are you now requiring that the State forms be used ?
We feel we have adequately addressed all concerns expressed in your letter and that the
plan, as revised, meets all requirements of Title 5 and the North Andover regulations and
Susan Sawyer
October 10, 2008
Page 2
we respectfully request that the plan be approved so that the owner may proceed with
construction and upgrade of their failed system.
We appreciate you prompt attention to this matter.
Yours truly,
MERRIMACK ENGINEERING SERVICES, INC.
U"C'Z�' C—�
William Dufresne
Project Manager
MERRIMACK ENGINEER1NG SERVICES, INC.
66 PARK STREET - ANDOVER, MASSACHUSETTS 01810
tkORTH
0
'"4jujs
Health Department
October 2, 2008
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover, MA 0 18 10
Re: Subsurface Sewage Disposal System Plan for 39 Granville Lane, Map 106C, Lot 51
Dear Mr. Nemchenok:
The proposed wastewater system design plan for the above site dated August 14, 2008 and
received on September 8, 2008 has been reviewed. Unfortunately, the plan cannot be approved
until the following items are corrected. The specific section in Title 5: 3 10 CMR 15.000, or
North Andover regulation that is not met by this design follows each item.
I . There are no test pits in the proposed soil absorption system area. A Local Upgrade
Approval for only having one test pit in the soil absorption system area cannot be
requested. A variance from Title 5, 3 10 CMR 15.102 must be requested.
2. Please provide a scaled profile of the system (NA 8.02 c).
3. Please specify all system components shall be marked magnetic marking tape including
the septic tank (3 10 CMR 15.221(12)).
4. Please note the outlet tee in the septic tank should extend 14" into the liquid and not 16"
(3 10 CMR 15.227(6)).
5. Please show all the legal boundaries of the property (3 10 CMR 15.220(4)(a)).
6. Please provide a north arrow on the site (3 10 CMR 15.220(4)(g)).
7. The design plan indicates the use of an effluent filter inside the septic tank. Please
indicate to the brand and model to be used. Also note the required annual maintenance
necessary (3 10 CMR 15.227(7)).
8. Please show all watercoarses or wetlands within 150' of the system (NA 8.02(r)).
9. Please provide a note that all the outlets of the d -box shall be at the same elevation (3 10
CMR 15.232(3)(b)).
10. Please provide soil evaluation forms 11 and 12 in accordance with 3 10 CMR 15.018(2).
1600 Osgood Street HEALTH DEPARTMENT Page 1 of 1
Building 20; Suite 2-36 E -Mail: healthdept@townofnorthandover.com
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
S Sincere
cer
Z /an Y. Sawyer, REHSc/R
S I s
'X S s
Public Health Director
cc: Jack Fotino
File
,%ORT#1
0
C14kjs
Health Department
October 2, 2008
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover, MA 0 18 10
Re: Subsurface Sewage Disposal System Plan for 39 Granville Lane, Map 106C, Lot 51
Dear Mr. Nemchenok:
The proposed wastewater system design plan for the above site dated August 14, 2008 and
received on September 8, 2008 has been reviewed. Unfortunately, the plan cannot be approved
until the following items are corrected. The specific section in Title 5: 3 10 CMR 15.000, or
North Andover regulation that is not met by this design follows each item.
1. There are no test pits in the proposed soil absorption system area. A Local Upgrade
Approval for only having one test pit in the soil absorption system area cannot be
requested. A variance from Title 5, 3 10 CMR 15.102 must be requested.
2. Please provide a scaled profile of the system (NA 8.02 c).
3. Please specify all system components shall be marked magnetic marking tape including
the septic tank (3 10 CMR 15.221(12)).
4. Please note the outlet tee in the septic tank should extend 14" into the liquid and not 16"
(3 10 CMR 15.227(6)).
5. Please show all the legal boundaries of the property (3 10 CMR 15.220(4)(a)).
6. Please provide a north arrow on the site (3 10 CMR 15.220(4)(g)).
7. The design plan indicates the use of an effluent filter inside the septic tank. Please
indicate to the brand and model to be used. Also note the required annual maintenance
necessary (3 10 CMR 15.227(7)).
8. Please show all watercoarses or wetlands within 150' of the system (NA 8.02(r)).
9. Please provide a note that all the outlets of the d -box shall be at the same elevation (3 10
CMR 15.232(3)(b)).
10. Please provide soil evaluation forms 11 and 12 in accordance with 3 10 CMR 15.018(2).
1600 Osgood Street HEALTH DEPARTMENT
Building 20; Suite 2-36 E -Mail: healthdept@townofnorthandover.com
North Andover, MA 01845 Phone: 978.688.9540
Page 1 of I
Fax: 978.688.8476
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
:Sincere
/ince
S san Y. Sawyer, REHS/R
Public Health Director
cc: Jack Fotino
File
161 14ORTH
"WO
S C US
Health Department
October 2, 2008
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover, MA 0 18 10
Re: Subsurface Sewage Disposal System Plan for 39 Granville Lane, Map 106C, Lot 51
Dear Mr. Nemchenok:
The proposed wastewater system design plan for the above site dated August 14, 2008 and
received on September 8, 2008 has been reviewed. Unfortunately, the plan cannot be approved
until the following items are corrected. The specific section in Title 5: 3 10 CMR 15.000, or
North Andover regulation that is not met by this design follows each item.
I . There are no test pits in the proposed soil absorption system area. A Local Upgrade
Approval for only having one test pit in the soil absorption system area cannot be
requested. A variance from Title 5, 3 10 CMR 15.102 must be requested.
2. Please provide a scaled profile of the system (NA 8.02 c).
3. Please specify all system components shall be marked magnetic marking tape including
the septic tank (3 10 CMR 15.221(12)).
4. Please note the outlet tee in the septic tank should extend 14" into the liquid and not 16"
(3 10 CMR 15.227(6)).
5. Please show all the legal boundaries of the property (3 10 CMR 15.220(4)(a)).
6. Please provide a north arrow on the site (3 10 CMR I 5.220(4)(g)).
7. The design plan indicates the use of an effluent filter inside the septic tank. Please
indicate to the brand and model to be used. Also note the required annual maintenance
necessary (3 10 CMR 15.227(7)).
8. Please show all watercoarses or wetlands within 150' of the system (NA 8.02(r)).
9. Please provide a note that all the outlets of the d -box shall be at the same elevation (3 10
CMR 15.232(3)(b)).
10. Please provide soil evaluation forms 11 and 12 in accordance with 3 10 CMR 15.018(2).
1600 Osgood Street HEALTH DEPARTMENT Page 1 of 1
Building 20; Suite 2-36 E -Mail: healthdept@townofnorthandover.com
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Sincere
in /e
c r
S san Y. Sawyer, REHS/R
Public Health Director
cc: Jack Fotino
File
Location
No. Dateo ?
TOWN OF NORTH ANDOVER
-0
AL
Certificate of Occupancy $
Building/Frame Permit Fee $
CH Foundation Permit Fee $
Other Permit Feepco $ OfT
Sewer Connection Fee $
Water Connection Fee $
TOTAL
3017 Building Inspector
Div. Public Works
04/05/99 12:53 MAW) DOM
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A .0 FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
'"""k"APPLICANT FILLS OUT THIS SECTION"'
APPLICANT J In N-- O)th 0�11N_b PHONE 81_03��
LOCATION: Assessors Map:t�umber.
PARCEL
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STREET L
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'"""OFFICIAL USE ONLY******N'
RECOMYENDATIONS OF TOWN AGENTS:
ILRVATION ADMINI R&OR DATE APPROVED
CONS ST
DATE- REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
i
FOOD IWECTOR-HEALTH DATE APPROVED
DATE REJECTED
IC INSPECTOR -HEALTH
COMMENTS -5-1
P- r- 2L A -
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
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Town of North Andover
HEALTH DEPARTMENT
CH
CHECK#: ae 7r D A T E:
LOCATION:
H/O NAME: Wl�ee-11* A
CONTRACT6R/NAME: Xe�A
3 4 G, 8
TYRe of Permit or License: (Check box)
$-
0 Animal
$
0 Body Art Establishment
$
0 Body Art Practitioner
$
0 Dumpster
$
0 Food Service - Type:
$
0 Funeral Directors
$
0 Massage Establishment
$
0 Massage Practice
$
0 Offal (Septic) Hauler
$
0 Recreational Camp
$
0 Sun tanning
$
0 Swimming Pool
$
0 Tobacco
$
• Trash/Solid Waste Hauler
$-
• Well Construction
$
SEPTIC Sustems:
[A-- oStic - Soil Testing $
0 Septic - Design Approval
$-
1:1 Septic Disposal Works Construction (DWC)
$
13 Septic Disposal Works Installers (DWI)
$-
0 Title 5 Inspector
$
0 Title 5 Report
$
0 Other (Indicate)
HVafth Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
h * ,
TOWN OF NORTH ANDOVER t4o T
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOJ`S'��RE SUITE 2-36
JX
NORT USE 'TS 0 1845 CH
Susan V. Sawyer, REHS, RS
Public Health Director
JUL 2 2 2
TO.WN. OF NORTH AND01
-1EALTH
APPLICATION FOR SOIL tE—STS
8 - 688.9540 — Phone
8.688.8476 — FAX
.townofnorthandover.com
DATE: C) e2 MAP & PARCEL:
LOCATION OF SOIL TESTS: 16-A rj y I
OWNER:—JAC4e!5-'-- f-42�—FiNW Contact #:
APPLICANT:—JAC—L"'-- 9�011 QO Contact #: 172 "�O
V
ADDRESS:. KAeNvf L-'L�- LA
ENGINEER: JjCW(j4H&CL-, W6jL.9eF0R ontact#: -7p If - 7 5; 5;
CERTIFIED SOIL EVALUATOR:
Intended Use of Land: Residential Subdivision e Family ome Commercial
Is This: Repair Testing:
Undeveloped Lott=-- U,
pgrade for Addition:
In the Lake Cochichewick Watershed? Yes No
THE FOLLOWING MUST BE INCLUDED WITH TIM FORM
> Proof of land ownership (Tax bill, or letter from owner permitting test)
> 8. 5" x 11 " Plotplan & Location of Testing (please indicate test pit sites on the pLan)
>- Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or upgrades.
GENERAL INFORMATION
> Only Certified Soil Evaluators may perform deep hole inspections.
> Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
> At least two deep holes and two percolation tests are required for each septic system disposal area.
> Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH
representative.
> Full payment will be required for all additional tests within two weeks of testing,
> Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health
showing the location of all tests (including aborted tests).
> Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval Date..
Signature of Conservation Agent. � - --C�
Date back to Health Department.- (stamp in):
DelleChWe, Pamela
From: DelleChiaie, Pamela
Sent: Friday, August 01, 2008 10:32 AM
To: Daniel Ottenheimer (info@millriverconsulting.com); Marianne Peters (Marianne Peters);
Randy Burley (rburley@millriverconsulting.com); Rowe Isaac (irowe@millriverconsulting.com)
Subject: FW: 39 Granville Lane - Missing plan showing test pits
Please read below. Also, I will scan in the application and send. Thanks.
Best Regards,
Pamela DelleChiaie
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 0 1845
*978.688.9540 - Phone
7 978.688.8476 - Fax
http://www.townofiiorthandover.com
healthdept@townofnorthandover.com
----- Original Message -----
From: DelleChiaie, Pamela
Sent: Friday, August 01, 2008 10:32 AM
To: 'brdufresne@comcast.net'
Subject: RE: 39 Granville Lane - Missing plan showing test pits
I will send it along with a copy of this e-mail. If Mill River needs additional information, I will have them
speak with you.
Best Regards,
Pamela DelleChiaie
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 0 1845
*978.688.9540 - Phone
7 978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
----- Original Message -----
From: brdufresne@comeast.net [mailto:brdufresne@comcast.net]
Sent: Friday, August 01, 2008 10:26 AM
To: DelleChiaie, Pamela
Cc: Sawyer, Susan
Subject: Re: 39 Granville Lane - Missing plan showing test pits
Pam
The horne ' owr;er-was unable to prAide m"e with a plot plan and I am out of the office today so unable to at least
4.1 send you a tax map. The testing is proposed 20-40 ft. directly in front of the house and there are no wetlands
within 100 feet of the site even though a plot plan wouldn't show wetlands any way. Does this really preclude
you from at least scheduling the test pits with Mill River. The application was submitted over 2 weeks ago and
the homeowners are anxious.
Please advise.
Thank you,
Bill
-------------- Original message ----------------------
From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
> Hi Bill,
• I am missing the plot plan showing where the test pits will be on this
• site. Please send them along so I can request soil testing with Mill
• River. You can scan the sheet and e-mail it to me, or fax it. Please
• get it to me ASAP, as I am on vacation next week. Thanks.
> Best Regards,
> Pamela DelleChiaie
> Health Department Assistant
> Town of North Andover
> 1600 Osgood Street
> Building 20, Suite 2-36
>North Andover, MA 0 1845
* *978.688.9540 - Phone
* 7 978.688.8476 - Fax
* http://www.townofnorthandover.com
* healthdept@townofnorthandover.com
Page I of I
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Friday, August 01, 2008 10:35 AM
To: Daniel Ottenheimer (info@millriverconsulting.com); Marianne Peters (Marianne Peters);
Randy Burley (rburley@millriverconsulting.com); Rowe Isaac (irowe@millriverconsulting.com)
Cc: Hughes, Jennifer
Please see attached. Thank you.
NO/ R-004M(S'
P101000.4 ZP40".064114110
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA o1845
11978.688-9540 - Phone
r 978.688-8476 - Fax
bqpj/yvi�,.tavNTofhorthando - ver.corn
healthdept@townoftiorthandoN,er.com
8/l/2008
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
-3
1600 OSGOO"i ;5 SUITE ' 2 P6
NORTH A�Xv. U E S01845
Susan Y. Sawyer, REHS, RS JUL 2 2 201� 9 8.688.9540 -Phone
Public Health Director 8.688,8476 - FAX
lt_ z 2 2
TOWN OF N%RTH A.N[�-OVER_h it wt
C)W L_ TH '_ __(�PjpwnofhorthanLoyer.com
-T
IHEA�.
Lj ki
wE W.townofnarthandover.com
TM'- 141
ALTH 01 --.PAR
APPLICATION FOR SOIL* TESTS
DATE: -7-1 (0 — P22 - MAP & PARCEL: to(, e
LOCATION OF SOIL TESTS:
OWNER. Contact#: t3092
APPLICANT C*o' ntact #:.. ':2
2 1300
ADDRESS:
ENGINEER- &Kkontact M (I TZ c7 37_��55;
CERTIFIED SOIL EVALUATOR.
Intended Use of Land: Residential Subdivision cFamily Commercial
Is nis Repair Testing.—kf' Undeveloped Lot Upgrade for Addition:
In the Lake Cochichewick Watershed? Yes No
THE FOLLOWING MUST BE INCLUDED WrM TEM FORM
> Proof of land ownership (Tax bill, or letter from owner permitting test)
> &S"X 11"B61 Plan & LRM$0.n Of Tewnr Ozkme hwkA* tat pit sues on uheLwj
>. Fee Of $9.�M per lot for new construction. This covers the minimum two deep holes and
two pe&olation tests required for each disposal area. Fee of S360.00 per lot for re irs or uperade&
n0a
GENERAL INFORMATION
> Only Cerfified Soil Evaluators may pexform deep hole inspections. -
> Only Mass. Registered Sanitariam and Professional Engineers can design septic plans.
> At least two deep holes and two percolation, tests are required for each septic system disposal area.
> Repairs require at least two deep holes and at least one percolation WA at the discretion of the BOB
reprwAxfttivc. I
> Full payment will be required fbr all additional tests within two weeks of testing.
> Within 45 days oftesting, a scaled plan (no smaller than I"-100') shall be submitted tp the Board of Health
showing the location of all tests (including aborted tests).
> Within 60 days of testing sod evaluation forms shall be submitted.
Plem* Do Not Write Below This Line
A royal Date:
N.A. Conserpadw Commission
SAV140re of Conservadon Area,,7
Date back to Heafth DVartmenr: (sjd;W in).
DelleChiaie, Pamela
From: brdufresne@comcast.net
Sent: Friday, August 01, 2008 10:26 AM
To: DelleChiaie, Pamela
Cc: Sawyer, Susan
Subject: Re: 39 Granville Lane - Missing plan showing test pits
E]
39 Granville Lane
- Missing... Pam
The home owner was unable to provide me with a plot plan and I am out of the office today so unable to at least
send you a tax map. The testing is proposed 20-40 ft. directly in front of the house and there are no wetlands
within 100 feet of the site even though a plot plan wouldn't show wetlands any way. Does this really preclude
you from at least scheduling the test pits with Mill River. The application was submitted over 2 weeks ago and
the homeowners are anxious.
Please advise.
Thank you,
Bill
-------------- Original message ----------------------
From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
> Hi Bill,
• I am missing the plot plan showing where the test pits will be on this
• site. Please send them along so I can request soil testing with Mill
• River. You can scan the sheet and e-mail it to me, or fax it. Please
• get it to me ASAP, as I am on vacation next week. Thanks.
• Best Regards,
• Pamela DelleChiaie
• Health Department Assistant
• Town of North Andover
• 1600 Osgood Street
• Building 20, Suite 2-36
>North Andover, MA 0 1845
* *978.688.9540 - Phone
* 7 978.688.8476 - Fax
* http://www.townoffiorthandover.com
* healthdept@townofnorthandover.com
DelleChialie, Pamela
From: brdufresne@comcast.net
Sent: Wednesday, July 08, 2009 8:34 AM
To: DelleChiaie, Pamela
Subject: Re: Septic - As Built - 39 Granville Lane - See notes
Hi Pam,
Yes, those ties are to the outlet cover which is to finish grade because there is an outlet tee filter. I will
revise the as -built plan and forward a new copy to your office.
Sorry for the confusion.
Bill Dufresne
----- Original Message -----
From: "Pamela DelleChiaie" <Pdellech@townofnorthandover.com>
To: "Bill Dufresne (brdufresne@comcast. net)" < b rd ufresne@com cast. net>
Cc: "Susan Sawyer" <ssawyer@townofnorthandover.com>
Sent: Monday, July 6, 2009 2:07:22 PM GMT -05:00 US/Canada Eastern
Subject: Septic - As Built - 39 Granville Lane - See notes
Hi Bill,
Please see Susan's notes on the As Built Checklist, and respond back. Thank you.
Pamela DefleChixe
Health Departmen t Assistant
TOWN OF NORTH ANDOVER
Health Department
1600 Osgood Street
Building 20; Suite 2-36
North Andover, MA 01845
978.688.9540 - Phone
978.688.8476 - Fax
pdellechiaie@townofnorthandover.com - E-mail
http://www.townofnorthandover.com - Website
T-3
0-54"
GR. M -C SAND
2.5Y514
0. W. T. -41
DA TE.- 6-22-09
EVALUATOR: B. DUFRESNE
INSPECTOR: S. SAWYER
AO TE** THIS PLAN & CERTIFICATION IS NOT
A WARRANTY OF THE SUBSURFACE DISPOSAL
SYSTEM. IT IS A RECORD OF THE LOCATION
AND ELEVATION OF THE EXISTING SYSTEM
COMPONENTS.
I HEREBY CERTIFY THAT THE SEWAGE
DISPOSAL SYSTEM HAS BEEN INSTALLED
IN ACCORDANCE WITH THE PROVISIONS
OF 310 CMR. 15-00 (TITLE 5) AND THE
APPROVED DESIGNS PLANS.
N/F FARR
EXIST. 4 6DR
*a.m. T.F.-joo,o
VMT
P-1 I r 0 4V
T-, LINSP.
LAW
44 lNFlLwTRkTcr
CHAMBERS
GWMLLE
AS BUILT PLAN
LANE
LOT 3
(1.59 AC.t)
N/F
ROBERT & MAUREEN
00 WL L
LANIGAN
RECEIVgD
JUL 0 8 2009
(p, /"--, -, 0 0
TOWN UF NORTH ANDOVER
HEALTH DEPARTMEE_'�
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH ANDOVER, MASS. /39 GRANVIUE LANE
AS PREPARED FOR
JACK FOTINO TM: 106C
DATE: 6-28-09 TL: 51
SCALE: 1"=40'
0 20 40 80
MERRIMACK ENGINEERING SERVICES
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
DelleChlaie, Pamela
From: Sawyer, Susan
Sent: Monday, June 29, 2009 1:49 PM
To: DelleChiaie, Pamela
Subject: peter breen
Peter says Bill D. is ok with 39 Granville, but I have not heard from Bill.
So, I did not let Mill River know yet that he will need a final
This is Peter's best # to be reached at 978 265-7580.
Thx
DelleChiaie, Pamela
From: Isaac Rowe [irowe@miliriverconsulting.com]
Sent: Tuesday, June 30, 2009 4:02 PM
To: 'Daniel Oftenheimer'; Grant, Michele; irowe@millriverconsulting.com; 'Marianne Peters';
DelleChiaie, Pamela; 'Randy Burley'; Sawyer, Susan
Subject: 39 Granville Lane
Attachments: 39 Granville Lane - Final Construction Inspection 6-30-09.doc
Susan,
Please find attached the final inspection report for the above referenced property.
Please let me know if you have any questions.
Thank you,
Isaac
Isaac M. Rowe, R.S.
Project Manager
Mill River Consulting
2 Blackbum Oenter
Gloucester, * 01930-2268
Phone: (978) 282-0014
Fax: (978) 282-0012
irowec@miliriverconsulting.com
www.millriverconsultin.g.com
t4ORTij
-CLIO 1 61 -
.6 0
0
00
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 39 Granville Lane
INSTALLER: Peter Breen
DESIGNER: Vladimir Nemchenok
PLAN DATE: 8/14/08
BOH APPROVAL DATE ON PLAN: 10/23/08
MAP: 106C LOT: 51
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: 6/30/09
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
[E Contractor reports any changes to design plan
Z Existing septic tank properly abandoned
[E internal plumbing all to one building sewer
Z Topography not appreciably altered
Comments: Tank was slightly moved due to actual field location of existing building
sewer line leaving the dwelling.
SEPTIC TANK
Building sewer in continuous grade, on compacted
firm base
1500 gallon tank has been installed
H-10 loading mono construction
Water tightness of tank has been achieved by
Visual testing
Inlet tee installed, centered under access port
1600 Osgood Street, North Andover, Mosso(husetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
Inspection Form June 2008
3439
Town of North Andover
HEALTH DEPARTMENT
CHECK#: D TE:
LOCATION:
H/0 NAME:
CONTRACT.6R NAME: e
Type of Permit or License: (Check box)
0 Animal $
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type.
$
0
Funeral Directors .
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
•
TrashIsolid Waste Hauler
•
Well Construction
$
SEPTIC Systems
0
Septic - Soil Testing
$
Z--'S"eptic - Design Approval
0
Septic Disposal Works Construction (DWC)
$
0
Septic Disposal Works Installers (DWf)
$_
0
Title 5 Inspector
$
0
Title 5 Report
$
0 Other. (Indicate) $
Health Agent Initials
White -Applicant Yellow -Health Pink -Treasurer
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36
NORTH ANDOVER, MASSACHUSETTS 0 1845 SACHU
Susan V. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health.Director 978.688.8476— FAX
E-MAIL: healthdeptgtownofriorthandover.com
WEBSITE: http://www.townofnorthandover.com
SEPTIC PLAN SUBMITTAL FORM
F R _ECIE I _VE D
Date of Submission:— - M - 0� SEP 0 8 2008
Site Location: Yz Ali L-A N e. 0 T
TOWN OF NORTH ANDOVER
LHEALTH DEPARTMENT
Engineer:__ Rf99VN WACk,-. 6061&XEYZ405i L
I ' -
New Plans? Yes $225/Plan Check# includes I" submission and one re-
review only)
Revised Plans?Yes $75/Plan Check #
Site Evaluation Forms Included? Yes V"" No
Local Upgrade Form Included? Yes V� No
Telephone #:(!I!Z 5- 7252-i:�� Fax #: h' 7.,5 q-75— 14-4
E-mail: " CK49-4-:;
Homeowner
Name: id W2
OFFICE USE ONLY
Whenthesu!bbm' i i complete (including check):
,psion is
Date stamp plans and letter
___�;`�Complete and attach Receipt
Copy File; Forward to Consultant
Enter on Log Sheet and Database
4 - . ro *
IL
A.!OCA-ti. DII! JAI
oumer's Namc: IJA44:;�
MlPMaMcl-----. I �44
Addm=
Td ff.-t&
Date: Vcdaj��ionr.IL— Soft (3.
Deep. Obsemittion Hole Logs
Elevation DO& SOUTerturil S.00:01or SOD blOttlIng.
% GmY4 Stone; etci
VF .6
VF, r-"A*Le
JOY
_IkA to lanAz— cll&ccon: k= rk Face—
Raft Wskerin the ad -211
DIX10 Pmoladon Tesft
Depth of P='
TIMC at 12
Time itt.9",
TIme at G"
Tim r. (.v -
Pate buanjlcb
-Pf!rffjrmr.d IB Mr
ituessedBr
arik
DelleChiaie, Pamela
Page I of I
From: Marianne Peters [mpeters@millriverconsulting.com]
Sent: Thursday, August 07, 2008 9:10 AM
To: 'Daniel Ottenheimer; 'Isaac Rowe'; Grant, Michele; DelleChiaie, Pamela; 'Randy Burley';
Sawyer, Susan
Subject: Granville rescheduled to 8/13, not 8/12
Bill Dufresne cannot do the 12th, so i39 Granville is now scheduled for Wed/Aug
13/9:00 a.m.
Sorry.
nx] Rig ht -click hereto download pictures. To help protect your privacy, Outlook prevented automatic download of this pictu
Marianne Peters
Office Manager
ph 800-377-3044
ph 978-282-0014
fx 978-282-0012
web: -,vww.miUriyerconLu1ting.co
8/11/2008
DelleChiaie, Pamela
Page I of 2
From: Isaac Rowe [irowe@millriverconsulting.com]
Sent: Thursday, August 14, 2008 8:25 AM
To: 'Daniel Ottenheimer'; Grant, Michele; irowe@millriverconsulting.com; 'Marianne Peters';
DelleChiaie, Pamela;'Randy Burley'; Sawyer, Susan
Subject: 39 Granville Lane
Susan,
Please find attached the soil testing results for the above referenced property. There is either a drainage
way or stream approximately 100'+/- to the left of the existing driveway. I'm sure your Con Com Agent will
be aware of this.
Let me know if you have any questions.
Thank you,
Isaac
Isaac M. Rowe, R.S.
Project Manager
Mill River Consulting
2 Blackburn Center
8/14/2008
Ile
zs—
a-I
-1 �lf
ks
0I
LA
!2 Irl
IT <
VJ
00
1 7
rCD
03-23-99 IU:56 From -OBJECT DESIGN +TB16T45010 T-023 P-01/03 F-691
X
Object Design
7N�
EOVID OF HEALTH
fM2 3 IM
"the database for component based computing"
Object Design Inc.
25 Mall Road
Burlington, NU
Phone: (781) 674-5159
Fax: (781)674-5259
Email: fotino@odi-com
www.objectdesign.com
Date: Tuesday, March 23, 1999
To: North Andover, Pe -q I
Sandy Star
Fax: 978-688-9542
From: Jack Fotino, Account Manager
Additional Pages: —2
Subject: Septic location for 39 Granville Ln Pool
Permmit. Notes by Neil Bateson.
03-23-99 10:56 From -OBJECT DESIGN +7816745010 T-023 P-02/03 F-691
BOSTON
SURVEY, INC.
P.O. Box 220 Charicstown, MA 02129
(617)242-1313 MAIN (617)242-1616 FAX
APPLICANT. F077NO
WCATION. 39 GRANVILLE LANE 085DICERT: 4057-82
CITV� STATE. NORTH ANDOVER. MA PLAN PEP: 7401
.k LOT 3
7-
2ST 5
f 0 vk
GRANVILLE LANE
PREPAREO., 11-03-1998
SCALE., I inch 60 feet
CERTIFIED TO, THE MORTGAGE PLACE INC.
11te Permanent sifucturcs 3ft approxinialcly loccued on (11c %Nb Accofilhig to Federal Entugency klariaporicta Agency
vim -d Ttwy cithcr con(amcd to the ci
vif lite incai toning WdItUnCes, ill C AAL(Otx snarm. life Major l"Winsvirsm op 4144 room Fy (at . I in all
Ow I;nw if construction, nr ard exemlM" (s&nl vi lint, alCa 4W91131W 34 ZOAC A;�.,Dqo.
f'ltq;F'hcn alinn under M.Cij.. Title V11. C112r, IQ
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Ni n n aint mmea jc(%w... NO 1 r Z� C 4 *� ad -"'Al, 11009AD Im shidam Trws
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NOTE - 11113 M " aboundaly or L410 ireMAW4 zwvoy Thh wait 1100 10 r'00(101111 And IKPA" $190411RIS 10 UW19aW Lean U408CIOM 4� adopted
1
'7,11W maz;altel-was rkyas'l CA limprA.w. of P -nm- Nut ; movQW:i. 230 CMn 4 05. and not; low any What purpow * pvc1ob"ad Thm ptan *." to be
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03-23-99 10:56 From -OBJECT DESIGN +7816745010 T-023 P-03/03 F-691
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SYSTEM PUMPING RECO",,-,--
'eCtIvED
DATE:
.TO\NN,,O' PS
EP,
SYSTEM OWNER & ADDRESS
Vic
S 1 6�� v -, lk
SYSTEM LOCATION
(example: left front of house)
DATEOFPUMPING: `4-4&-6:S QUANTITY PUMPED: 10 () c-) GALLONS
CESSPOOL: NO j YES SEPTIC TANK: NO_ YES 4'zz/
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFEMED To: G.L.S.13 tJ Lowell Waste
DATE:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
2FO4, AD ,
GraAvt
M-c LIA
(example: left front of house)
DATE OF PUMPING: 1.6;n2 - 0,;, QUANTITY PUMPED I e00 GALLONS
CESSPOOL: NO /YES SE TIC TANK: NO YES
NATURE OF . SERVICE: ROUTINE ;7EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY -
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: - L �"b
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System Pumping_ Record
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0(
Date of Pumping: -5-00
Cesspool: No Yes Ll
System Location
(--rtctvw �A � -
Quaittity Pumped: 6L,�Z� gallons
SepticTank: No 11 Yes L�--�
System Pumped by: Fettedea License #
Contents transreurred to : Greater Lawrence Sanitary District
Date:
Inspector: .
0 ------- R FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
applicant and/or landowner from compliance with any applicable or requirements.
***.*********APPLICANT FILLS OUT THIS SECTION*****—
APPLICANT -, *-- lj'� r) P HONE 5)
LOCATION: Assesso(s Map.Number.
PARCEL
SUBDIVISION LOT (S)
STREET_(1V-11nV�ft Lc�r� 4 ST. NUMBER
IVql%o(pv ...... p
OFFICIAL USE ONLY****** -***J******* �0() I
REC��WENDATIONS OF TOWN AGENTS:
CONS�RVATION ADMINIVRA�TOR DATE APPROVED
COMMENTS -.,/ Y
TOWN PLANNER
COMMENTS
FOOD 11`�S-PECTOR-HEALTH
IC INSPECTOR -HEALTH
COMMENTS
4- 25 a i -
DATE- REJECTED_
ato
DATE APPROVED
DATE REJECTED -
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
I
RECEIVED BY BUILDING INSPECTOR DATE
Commonwealth of Massachusetts
AA.--&-O�-,assachusetts
System Pumping Record
Systent Owner-
IFO V\CD
-31
Date of Pumping
Cesspool: No 14--�Yes Ll
System Location
. (39 Gcc,(�Ue t -K,
Quafitity Pumped: k� g allons
Septic Tank: No 11 Yes
System Pumped by: Fefre.4,0,re 5,rj&n
,,ftae4 License
Contents transrerrred to : Greater Lawrence Sanitary District
Date:
Inspector:
Commonwealth of Massachusetts
City/Town of I JUN 15 2007
TOWN OF NORT H ANDOVER
System Pumping Record HEALTH DEPARTMM NT
L _ E
Form 4
DEP has provided this form for use by local Boards of Health.. The System Pumping Record must
be submitted to the local Board of -Health or other approving authority.
A. Facility Information
Important:
When filling out
forms on the
1
System Location:
computer, use
only the tab key
to move your
Address 11 jj'�
4:;1111
. ... . .. .. . . . . . . . . . 111�111 111111'iijjj�<"'
cursor - do not
use thereturn
Cityrrown State Zip Code
key.
2.
System Owner:
Name
Address (if different from location)
City[Town State Z'
I elephone Number
Pumping Retord
Date. of Pumpind
6a-te 2- Quantity Pumped:
Gallons
3.
Type of system: El Cesspool(s) Septic Tank El TightTank
El Other (describe):
4.
Effluent Tee, Filter present? El Yes �No If yes, was it cleaned? El Yes I El No
.6.
Condition of System -1
6.
S t PU pe(;Lpy.:
Name Vehicle License Number
Cor�pany
Location e qon.te-nts wereMsposed:
Sign, re H uler Date
http://www.r�ass,gqv/de�/wa-ter/'approvals/t5fonns.htm#inspect
t5form4.doc- 06103
System _urnping Record - Page 1 of 1